What is Peyronie’s disease

Peyronie’s disease is a disorder in which fibrous scar tissue, called a plaque, forms inside the penis. The plaque (scar tissue) builds up inside the tissues of a thick, elastic membrane called the tunica albuginea. The most common area for the plaque is on the top or bottom of the penis. Peyronie’s disease plaques mostly (70% of the time) form on the top (or dorsal side) of the penis. The plaques make the tunica albuginea less flexible and may cause the penis to bend upwards when it stiffens. When plaques form on the bottom or side of the penis, the bend will be downward or sideways. As the plaque builds up, the penis will curve or bend, which can cause painful erections. Curves in the penis can make sexual intercourse painful, difficult, or impossible.

Sometimes plaques form that go all the way around the penis. These plaques most often don’t cause curving but may cause the shaft of the penis to narrow like the neck of a bottle (sometimes called “bottle-necking” or “waisting”). In bad cases, the plaque may collect calcium and become very hard, almost like a bone. Men may also notice that their penis has shrunk or gotten shorter.

Other signs that you may have Peyronie’s disease are:

• bent/curved penis
• lumps in the penis
• painful erections
• soft erections
• having trouble with sex because of a bent/curved penis

Peyronie’s disease begins with inflammation, or swelling, which can become a hard scar.

The plaque that develops in Peyronie’s disease is not the same plaque that can develop in a person’s arteries. The plaque seen in Peyronie’s disease is benign, or noncancerous, and is not a tumor. Peyronie’s disease is not contagious or caused by any known transmittable disease.

Early researchers thought Peyronie’s disease was a form of impotence, now called erectile dysfunction. Erectile dysfunction happens when a man is unable to achieve or keep an erection firm enough for sexual intercourse. Some men with Peyronie’s disease may have erectile dysfunction. Usually men with Peyronie’s disease are referred to a urologist—a doctor who specializes in sexual and urinary problems.

Researchers estimate that Peyronie’s disease may affect 1 to 23 percent of men between 40 and 70 years of age ¹. However, the actual occurrence of Peyronie’s disease may be higher due to men’s embarrassment and health care providers’ limited reporting ². Peyronie’s disease is rare in young men, although it has been reported in men in their 30s ¹. The chance of developing Peyronie’s disease increases with age.

Interestingly, more Peyronie’s disease cases have been noted in recent years. This may be because new meds for erectile dysfunction (ED) have come to market, and health care providers may notice Peyronie’s disease in men seeking help for erectile dysfunction. For this reason, the number of Peyronie’s disease cases reported will likely keep growing.

Peyronie’s disease can make your quality of life worse. Over 75 out of 100 men with Peyronie’s disease are stressed and depressed because of it. Unfortunately, many men with Peyronie’s disease are embarrassed and choose to suffer in silence rather than get help.

Peyronie’s disease sometimes goes away on its own. But in most cases, it will remain stable or worsen. Treatment might be needed if the curvature is severe enough that it prevents successful sexual intercourse.

What is the penis?

Used for urination and sexual intercourse, the penis is made up of two erectile cylinders (corpora cavernosa) that enlarge with blood during erection. A tough fibrous, partially elastic outer casing surrounds the cavernosa. The corpus spongiosum surrounds the urethra (urinary tube), a tube that runs from the bladder to the end of the penis. The urethra carries urine and semen out of the body. The main roles of the penis are to carry urine out of the body and sperm into the woman’s vagina. The 3 tubes (corpora cavernosa, corpus spongiosum and the urethra) are wrapped together by a very tough fibrous sheath called the tunica albuginea. During sex, the stiffness of the penis makes it hard enough to push into the woman’s vagina. Then the urethra acts as a channel to carry semen into the vagina.

Figure 1. Male reproductive system

Figure 2. Penis (cross section)

How does an erection occur?

An erection occurs when blood flow increases into the penis, making it expand and become firm. Two long chambers inside the penis, called the corpora cavernosa, contain a spongy tissue that draws blood into the chambers. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The tunica albuginea encases the corpora cavernosa. The urethra, which is the tube that carries urine and semen outside of the body, runs along the underside of the corpora cavernosa in the middle of a third chamber called the corpus spongiosum. Read about the urinary tract.

An erection requires a precise sequence of events:

• An erection begins with sensory or mental stimulation, or both. The stimulus may be physical contact or a sexual image or thought.
• When the brain senses a sexual urge, it sends impulses to local nerves in the penis that cause the muscles of the corpora cavernosa to relax. As a result, blood flows in through the arteries and fills the spaces in the corpora cavernosa like water filling a sponge.
• The blood creates pressure in the corpora cavernosa, making the penis expand.
• The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining the erection.
• The erection ends after climax or after the sexual urge has passed. The muscles in the penis contract to stop the inflow of blood. The veins open and the extra blood flows out of the penis and back into the body.

Figure 3. How erection occurs – when a male becomes sexually aroused, nerve impulses increase blood flow to both corpora cavernosa. This sudden influx of blood causes an erection by expanding, straightening and stiffening the penis.

Peyronie’s Disease Stages

Peyronie’s disease is often split into 2 stages: the acute phase and the chronic phase. During both phases, the bent/curved penis may cause problems with sex. You also may have erectile dysfunction.

1. Acute Phase: The acute phase lasts for 6 to 18 months. During this time, the plaques form in the penis, the bending/curving of the penis gets worse, and you may feel pain when your penis gets hard.
2. Chronic Phase: The chronic phase is when the plaque stops growing and the penis doesn’t bend any further. If there was pain with erection during the acute phase, it often will have ended by this time.

Peyronie’s disease complications

Complications of Peyronie’s disease may include:

• the inability to have sexual intercourse
• erectile dysfunction
• anxiety, or stress, about sexual abilities or the appearance of the penis
• stress on a relationship with a sexual partner
• problems fathering a child because intercourse is difficult

Does Peyronie’s Disease Turn into Cancer?

The plaque seen in Peyronie’s disease is benign, or noncancerous, and is not a tumor. Cells taken from Peyronie’s plaques act like cancer cells in some ways, such as not dying normally and forming tumors when put into mice with no immune systems. But there has NEVER been a case of Peyronie’s disease that has turned into a cancer in a human.

If you have other symptoms that aren’t often seen with Peyronie’s disease, such as external bleeding, trouble peeing, or penile pain that lasts for a long time, your health care provider may take a sample of the tissue (biopsy) for further study.

Are Men with Peyronie’s Disease More Likely to Get any Other Illnesses?

Some men with Peyronie’s disease (about 13 out of 100) get fibrosis in other parts of the body. The most common sites are the hands and feet. Dupuytren’s contracture, in which fibrosis occurs in the tissue of the palm, is one health problem linked to Peyronie’s disease. Dupuytren’s contracture may lead to permanent bending of the outer fingers. It isn’t clear what causes plaque to form in either disease, or why men with Peyronie’s disease are more likely to get Dupuytren’s contracture.

Peyronie’s disease causes

Medical experts do not know the exact cause of Peyronie’s disease. Many believe that Peyronie’s disease may be the result of:

• acute injury to the penis
• chronic, or repeated, injury to the penis
• autoimmune disease—a disorder in which the body’s immune system attacks the body’s own cells and organs

It’s thought Peyronie’s disease generally results from repeated injury to the penis. For example, the penis might be damaged during sex, athletic activity or as the result of an accident. However, most often, no specific trauma to the penis is recalled. In some men, Peyronie’s disease comes on gradually and doesn’t seem to be related to an injury. Researchers are investigating whether Peyronie’s disease might be linked to an inherited trait or certain health conditions.

During the healing process, scar tissue forms in a disorganized manner, which might then lead to a nodule that you can feel or development of curvature. In Peyronie’s disease, when the penis becomes erect, the region with the scar tissue doesn’t stretch, and the penis bends or becomes disfigured and possibly painful.

Injury to the Penis

Medical experts believe that hitting or bending the penis may injure the tissues inside. A man may injure the penis during sex, athletic activity, or an accident. Injury ruptures blood vessels, which leads to bleeding and swelling inside the layers of the tunica albuginea. Swelling inside the penis will block blood flow through the layers of tissue inside the penis. When the blood can’t flow normally, clots can form and trap immune system cells. As the injury heals, the immune system cells may release substances that lead to the formation of too much scar tissue. The scar tissue builds up and forms a plaque inside the penis. The plaque reduces the elasticity of tissues and flexibility of the penis during erection, leading to curvature. The plaque may further harden because of calcification––the process in which calcium builds up in body tissue.

Connective Tissue and Autoimmune Disorders

Some medical experts believe that Peyronie’s disease may be part of an autoimmune disease. Normally, the immune system is the body’s way of protecting itself from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. Men who have autoimmune diseases may develop Peyronie’s disease when the immune system attacks cells in the penis. This can lead to inflammation in the penis and can cause scarring. Medical experts do not know what causes autoimmune diseases. Some of the autoimmune diseases associated with Peyronie’s disease affect connective tissues. Connective tissue is specialized tissue that supports, joins, or separates different types of tissues and organs of the body.

Men who have certain connective tissue and autoimmune disorders may have a higher chance of developing Peyronie’s disease. A common example is a condition known as Dupuytren’s disease, an abnormal cordlike thickening across the palm of the hand. Dupuytren’s disease is also known as Dupuytren’s contracture. Although Dupuytren’s disease is fairly common in older men, only about 15 percent of men with Peyronie’s disease will also have Dupuytren’s disease.

Other connective tissue disorders associated with Peyronie’s disease include:

• plantar fasciitis––inflammation of the plantar fascia, thick tissue on the bottom of the foot that connects the heel bone to the toes and creates the arch of the foot
• scleroderma––abnormal growth of connective tissue, causing it to get thick and hard; scleroderma can cause swelling or pain in muscles and joints

Autoimmune disorders associated with Peyronie’s disease include:

• systemic lupus erythematosus––inflammation and damage to various body tissues, including the joints, skin, kidneys, heart, lungs, blood vessels, and brain
• Sjögren’s syndrome––inflammation and damage to the glands that make tears and saliva
• Behcet’s syndrome––inflammation of the blood vessels

Family History of Peyronie’s Disease

Medical experts believe that Peyronie’s disease may run in some families. For example, a man whose father or brother has Peyronie’s disease may have an increased chance of getting the disease.

Aging

The chance of getting Peyronie’s disease increases with age. Age-related changes in the elasticity of tissues in the penis may cause it to be more easily injured and less likely to heal well.

Other Factors

Not all men who suffer mild trauma to the penis get Peyronie’s disease. For this reason, most researchers believe there must be genetic or environmental reasons Peyronie’s disease plaques form. Men with certain connective tissue disorders (such as Dupuytren’s contractures or tympanosclerosis). Certain health issues, such as high blood sugar, tobacco use, or past pelvic trauma, may also lead to wound healing problems, and may help cause Peyronie’s disease.

Figure 4. Peyronie’s disease

Peyronie’s disease prevention

Researchers do not know how to prevent Peyronie’s disease.

Peyronie’s disease signs and symptoms

The signs and symptoms of Peyronie’s disease may include:

• hard lumps on one or more sides of the penis
• pain during sexual intercourse or during an erection
• a curve in the penis either with or without an erection
• narrowing or shortening of the penis
• erectile dysfunction

Symptoms of Peyronie’s disease range from mild to severe. The curvature associated with Peyronie’s disease might gradually worsen or appear quickly. At some point, however, it typically stabilizes. In many cases, the pain decreases over time, although the curve in the penis may remain. In some cases, both the curvature and pain associated with Peyronie’s disease improve without treatment. In milder cases, symptoms may go away without causing a permanent curve. Pain during erections usually improves within one to two years, but the scar tissue and curvature often remain.

Peyronie’s disease diagnosis

Your health care provider may be able to tell if you have Peyronie’s disease with only a physical exam. The hard plaques can most often be felt whether the penis is stiff or not. To check how the penis curves, your health care provider may inject a drug into your penis to make it stiff.

A urologist diagnoses Peyronie’s disease based on

• a medical and family history
• a physical exam
• imaging tests

Medical and Family History

Taking a medical and family history is one of the first things a urologist may do to help diagnose Peyronie’s disease. He or she will ask the man to provide a medical and family history, which may include the following questions:

• What is the man’s ability to have an erection?
• What are the problems with sexual intercourse?
• When did the symptoms begin?
• What is the family medical history?
• What medications is the man taking?
• What other symptoms is the man experiencing?
• What other medical conditions does the man have?

Physical Exam

A physical exam may help diagnose Peyronie’s disease. During a physical exam, a urologist usually examines the man’s body, including the penis.

A urologist can usually feel the plaque in the penis with or without an erection. Sometimes the urologist will need to examine the penis during an erection. The urologist will give the man an injectable medication to cause an erection.

Imaging Tests

To help pinpoint the location of the plaque buildup inside the penis, a urologist may perform:

• ultrasound of the penis
• an x-ray of the penis

For both tests, a specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. The patient does not need anesthesia.

• Ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. Ultrasound is used to see where the plaque is, check for calcium buildup, and show how the blood flows in your penis.
• X-ray. An x-ray is a picture created by using radiation and recorded on film or on a computer. The amount of radiation used is small. The man will lie on a table or stand during the x-ray, and the technician may ask the man to change positions for additional pictures.

Peyronie’s disease treatment

The goal of treatment is to reduce pain and restore and maintain the ability to have intercourse. Men with small plaques, minimal penile curvature, no pain, and satisfactory sexual function may not need treatment until symptoms get worse. Peyronie’s disease often resolves on its own without treatment.

In a very few number of cases (about 13 out of 100), Peyronie’s disease goes away without being treated. Many health care experts suggest treating the disease without surgery for the first 12 months after the disease is first noticed.

Men with small plaques, not much curving of the penis, no pain, and no problems with sex may not need to be treated. If you need to be treated, there are many choices.

A urologist may recommend changes in a man’s lifestyle to reduce the risk of erectile dysfunction associated with Peyronie’s disease.

Lifestyle Changes

A man can make healthy lifestyle changes to reduce the chance of erectile dysfunction associated with Peyronie’s disease by:

• quitting smoking
• reducing alcohol consumption
• exercising regularly
• avoiding illegal drugs

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing Peyronie’s disease.

Nonsurgical Treatments

Nonsurgical treatments include medications and medical therapies.

Medications

A urologist may prescribe medications aimed at decreasing a man’s penile curvature, plaque size, and inflammation. A man may take prescribed medications to treat Peyronie’s disease orally––by mouth––or a urologist may inject medications directly into the plaque. Verapamil is one type of topical medication that a man may apply to the skin over the plaque.

Drug therapy may help men who are badly affected by the disease during the acute phase. There haven’t been enough studies to tell exactly how well these drugs work, though.

Oral medications. Oral medications may include:

• Vitamin E : Vitamin E is an antioxidant that’s popular because of its mild side effects and low cost. Studies as far back as 1948 show that taking vitamin E may make plaques smaller and help straighten the penis. But most of these studies did not compare a group of people using vitamin E to a group of people who did not (a control group). A few studies of vitamin E that used a control group suggest that vitamin E doesn’t work better than placebo. (A placebo is a pill with no drugs in it – a “sugar pill.”)
• Potassium para-aminobenzoate (Potaba) : Small studies with placebo controls show that this vitamin B-complex helps reduce plaque size, but not the curve. Unfortunately, it is costly and patients need to take 24 pills per day for 3 to 6 months. It also can upset your stomach, so many men stop taking it.
• Tamoxifen: This non-steroidal, anti-estrogen drug has been used to treat desmoid tumors, which are like the plaques in Peyronie’s disease. There are only a few controlled studies of this drug and they haven’t shown that tamoxifen works better than placebo.
• Colchicine: Colchicine is an anti-swelling agent that has been shown to be slightly helpful in a few small studies without controls. Many patients taking colchicine get stomach problems and stop taking the drug. It hasn’t been proven to work better than placebo.
• Acetyl-L-carnitine: Carnitine is an antioxidant drug that lowers swelling to help wounds heal. Studies without controls show some benefit. But a recent controlled study didn’t show it to work better than placebo.
• Pentoxifylline

Penile Injections

Injecting a drug right into the plaque brings higher doses of the drug to the problem than when a drug is taken by mouth. Plaque injection is often used for men with acute phase disease who aren’t sure they want to have surgery. The skin is often numbed before the shot to reduce pain.

Medications injected directly into plaques may include:

• Verapamil injections: Verapamil is mostly used to treat high blood pressure. Some studies suggest that verapamil injection also works for penile pain and curving. Verapamil appears to be a good, low-cost option for Peyronie’s disease. More controlled studies are needed to prove how well it works.
• Interferon alpha 2b: Interferon is a protein made in the body that helps control swelling. It has been shown to help control scarring, perhaps by slowing down the rate that scar tissue builds and by making an enzyme that breaks down the scar tissue. A large-scale test of interferon injection for Peyronie’s disease showed that this treatment can help. But more studies are needed.
• Steroids
• Collagenase (Xiaflex): Collagenase is made in the body and breaks down certain tissues. Studies have shown that injecting collagenase into plaques helped fix Peyronie’s disease. This drug (Xiaflex®) is now approved in the U.S. for treatment of men with penises curving more than 30 degrees.

To date, collagenase is the first and only medication specifically approved for Peyronie’s disease.

Medical therapies

A urologist may use medical therapies to break up scar tissue and decrease plaque size and curvature. Therapies to break up scar tissue may include

• high-intensity, focused ultrasound directed at the plaque
• radiation therapy––high-energy rays, such as x-rays, aimed at the plaque
• shockwave therapy––focused, low-intensity electroshock waves directed at the plaque

A urologist may use iontophoresis––painless, low-level electric current that delivers medications through the skin over the plaque––to decrease plaque size and curvature.

A urologist may use mechanical traction and vacuum devices aimed at stretching or bending the penis to reduce curvature.

Peyronie’s disease exercises

Other ways to treat Peyronie’s disease are being studied. But there isn’t enough data on them yet to prove they work.

Some small studies have shown that stretching the penis for 2 to 8 hours a day for at least 6 months may help restore length and curving.

Treating the penis with ultrasound, radiation, shock-waves, heat, and verapamil on the skin are also being studied. These, for the most part, are not proven and are not recommended by experts in the field.

Peyronie’s disease surgery

Surgery is reserved for men with severe, disabling penile deformities that make it hard to have sex. Most health care providers suggest putting off surgery until the plaque and curving have stopped getting worse, and the patient has been pain-free for at least 9 to 12 months. Medical experts suggest waiting 1 year or more from the onset of symptoms before having surgery because the course of Peyronie’s disease is different in each man.

Before surgery, your health care provider may check the blood flow in the penis by injecting a drug that will make it stiff, and may also look inside the penis using ultrasound. These tests help show what is going on inside your penis (such as whether there is also erectile dysfunction) so your health care provider can decide which type of surgery is best for you.

Medical experts recommend surgery for long-term cases when:

• symptoms have not improved
• erections, intercourse, or both are painful
• the curve or bend in the penis does not allow the man to have sexual intercourse

Some men may develop complications after surgery, and sometimes surgery does not correct the effects of Peyronie’s disease––such as shortening of the penis. Some surgical methods can cause shortening of the penis.

There are 3 basic ways to fix Peyronie’s disease with surgery:

1. making the side of the penis opposite the plaque shorter (plication)
2. making the side of the penis that curves longer (grafting)
3. placing a prosthetic device inside the penis (device implantation)

Surgery to Shorten the Side of the Penis Opposite the Plaque/Curve (Plication)

This type of surgery can be done either by cutting out small pieces of tissue on the outside of the curve and sewing it closed or by folding the tissue and pulling it together with surgical thread. The surgery is most often safe, easy for the surgeon to do, and has a low risk of problems (such as bleeding or making erectile dysfunction worse). A drawback is that this type of surgery can make the penis shorter. This surgery is better for men with mild or no erectile dysfunction, mild-to-moderate penile curving, and a long penis.

Surgery to Make the Side of the Penis that is Curved Longer (Grafting)

This type of surgery is used when the penile curve is severe or the shaft has become very narrow. The surgeon cuts the plaque to ease tension, and may remove some of the plaque. The space that’s left is then filled with a graft.

In most cases, this surgery won’t make the penis much shorter. But it’s harder for the surgeon to do and there is a risk it could make erectile dysfunction worse. This surgery is often only recommended for cases of severe deformity in men who are able to get erections hard enough for sex.

Types of Grafts

Grafting surgery moves tissue from one place on the body to another. It can also replace missing tissue on your body with donor tissue or a laboratory-made replacement. Your surgeon will help you decide which type of graft should be used to fill the space left by taking out the plaque.

There are 2 types of grafts that are most often used:

• Autologous tissue grafts: These are grafts made of tissue taken from another part of your body during surgery. Some sources of grafts used for Peyronie’s disease are a vein from your leg (saphenous vein) or skin from behind your ear (temporalis fascia). Since autologous grafts are living tissue, they often grow into the surgical site much better than some other materials. A drawback to using an autologous graft is that the surgeon must make a second cut to harvest the graft.
• Non-autologous allografts: These are sheets of tissue that are commercially made from human or animal sources. Before use, they are sterilized and treated to remove anything that could cause infection. These grafts act as supports for your body to grow fresh, healthy tissue on while they are slowly absorbed by your body. Allografts are strong, easy to work with, and well tolerated by most patients. Man-made materials such as Dacron® mesh or GORE-TEX® aren’t often used for Peyronie’s surgeries now. These materials can cause fibrosis that can make the deformity worse.

Penile Prosthetic Devices (Device Implantation)

An inflatable pump or moldable silicone rods placed inside the penis are good options for men with Peyronie’s disease and moderate-to-severe ED. In most cases, this will straighten the penis and allow it to get stiff enough for sex. If the device doesn’t straighten the penis enough, the surgeon may straighten it more by modeling the plaque against the stiff prosthesis or by cutting the plaque and using a graft to cover the opening.

After surgery for Peyronie’s disease

A light pressure dressing is often left on the penis for 24 to 48 hours after surgery to stop bleeding and hold the repair in place. During surgery, a tube (catheter) will have been placed through the end of the penis into the bladder, and this may still be in place when you wake up. The tube is often removed in the recovery room.

Most patients leave the hospital the same day after surgery or the next morning. You may be given antibiotics to take for a few days to lower the risk of infection and help keep swelling down, as well as pain meds. You shouldn’t have sex for at least 6 weeks after surgery, or longer in cases of complex repairs.

1. What is Peyronie’s Disease?.http://www.urologyhealth.org/urologic-conditions/peyronies-disease?article=115[↩][↩]
2. (What is Peyronie’s Disease?.http://www.urologyhealth.org/urologic-conditions/peyronies-disease?article=115[↩]